Background

In England in 2001 oesophagogastric cancer surgery was centralized. The aim of this study was to evaluate whether centralization of oesophagogastric cancer to high‐volume centres has had an effect on mortality from different emergency upper gastrointestinal conditions.

Method

The Hospital Episode Statistics database was used to identify patients admitted to hospitals in England (1997–2012). The influence of oesophagogastric high‐volume cancer centre status (20 or more resections per year) on 30‐ and 90‐day mortality from oesophageal perforation, paraoesophageal hernia and perforated peptic ulcer was analysed.

Results

Over the study interval, 3707, 12 441 and 56 822 patients with oesophageal perforation, paraoesophageal hernia and perforated peptic ulcer respectively were included. There was a passive centralization to high‐volume cancer centres for oesophageal perforation (26·9 per cent increase), paraoesophageal hernia (19·5 per cent increase) and perforated peptic ulcer (23·0 per cent increase). Management of oesophageal perforation in high‐volume centres was associated with a reduction in 30‐day (HR 0·58, 95 per cent c.i. 0·45 to 0·74) and 90‐day (HR 0·62, 0·49 to 0·77) mortality. High‐volume cancer centre status did not affect mortality from paraoesophageal hernia or perforated peptic ulcer. Annual emergency admission volume thresholds at which mortality improved were observed for oesophageal perforation (5 patients) and paraoesophageal hernia (11). Following centralization, the proportion of patients managed in high‐volume cancer centres that reached this volume threshold was 88·0 per cent for oesophageal perforation, but only 30·3 per cent for paraoesophageal hernia.

Conclusion

Centralization of low incidence conditions such as oesophageal perforation to high‐volume cancer centres provides a greater level of expertise and ultimately reduces mortality.

Your comments

2 Comments

Peter Coe

2 years ago

This paper aimed to determine whether outcomes from emergency benign upper gastro-intestinal (GI) conditions are improved in high-volume oesophago-gastric (OG) cancer centres. The authors found that admission to a ‘high-volume centre’ was associated with lower mortality for oesophageal perforation (OP) but not for para-oesophageal hernia (POH) or perforated peptic ulcer (PPU). They propose that this is due to insufficient centralisation of management of POH but that for PPU the lack of a volume-outcome relationship argues against the need for centralisation. We agree that OP should be managed by tertiary centres but posit that the lack of improvement in outcome for POH and PPU is related to unmeasured confounders.

Separation based on cancer resection volume may not split units into those with specialist upper GI experience and those without. A key factor for improved outcome is a laparoscopic approach (1). Yet in the UK only 15% of gastrectomies and 39% of oesophagectomies for cancer are performed in this manner (2). Comparatively, high-volume advanced benign units have the expertise to perform these cases laparoscopically. In addition, defining ‘high-volume’ centres as those performing over 20 OG cancer resection per-year is not in keeping with UK guideline minimum resection volume meaning some may be unable to provide consistent specialist input into emergency care (3).

This study should not stop commissioners from pursuing the question of whether centralisation could improve outcomes. But we believe that future studies investigating the effect of specialisation should classify centres based on volume of both benign and cancer complex upper GI procedures.

Coe et al. raised “laparoscopic management of emergency para-oesophageal hernia” as an “unmeasured confounder” in our manuscript (1) and proposed defining high-volume centres for both benign and cancer conditions. The HES dataset used for hiatus hernia does not allow the examination of technical factors specifically laparoscopic approach. We agree that including high-volume benign centres and the utilisation of laparoscopic approach would be informative for future analysis. Nevertheless, the following points should be examined with caution. The utilisation of laparoscopic approach in cancer is not only determined by the availability of laparoscopic skills. Many upper gastrointestinal units selectively use the laparoscopic approach in cancer but extensively employ it in complex benign and redo surgery. It is the strategy of radical lymphadenectomy that determines the approach, “Laparoscopic phase of oesophagectomy is not a glorified fundoplication”. Secondly, while cancer units have 24-hours cover for surgery and other interventional infrastructure, the NHS does not provide/afford such workforce for benign units. Thirdly, gangrenous para-oesophageal hernia requires resection that may be through transthoracic approach. We have shown that high-volume oesophago-gastric cancer surgeons have a greater propensity to surgically intervene early for obstructed or gangrenous para-oesophageal hernia, with surgical intervention reducing mortality (2). We used the median of the dataset (1997–2012) of 20 cancer resections as the annual threshold to define high-volume centres (3) as centralisation took place from 2005 onwards and hence the volume-threshold in 2010 audit report does not represent the study period. In summary, the surgical approach is a component of a system that determines the outcome.

Sheraz R. Markar George B. Hanna

Department of Surgery and Cancer Imperial College London United Kingdom g.hanna@imperial.ac.uk